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A respiratory consultant who does home visits and a full-time psychologist who sees referred COPD patients – Dr Gurkirit Kalkat explains how a radical redesign has improved care for patients

Three years ago we realised we had a real problem with COPD in Barking and Dagenham. There was a high rate of admissions to hospital but a low prevalence rate of COPD as patients were not being diagnosed appropriately.

We decided to set up a respiratory service and it developed into a full-time consultant-led service in the community involving respiratory nurses and a psychologist.

We now have a service to which GPs can refer patients for diagnosis. It covers 42 practices, with a population of 160,000. The scheme also sees patients who have been admitted to hospital for COPD, to try to identify the reasons behind their admission and prevent future admissions. 41215435If patients become acutely ill and GPs feel they need to be seen quickly but don't need hospital admission, we can call upon the consultant who might visit the patient at home or see them at the clinic. Having seen the acute patients, the consultant or the respiratory nurses then follow them up.

The team will also assess patients for their suitability to be given oxygen therapy at home. They provide patients who have moderate to severe COPD with an emergency pack of antibiotics at home for use during exacerbations.

As a result of the service, many GPs have become interested in doing their own spirometry training. The scheme is not just a focus for referral, but also of training for local GPs, a lot of which has been done by the consultant and the respiratory nurses.

Many COPD patients tend to have psychological problems. If these are not properly dealt with, they can lead to exacerbations. The patients are often depressed or anxious, they may suffer panic attacks and not know how to tell whether they are suffering a panic attack or COPD.

Evidence from similar services and advice from consultants suggested that having a psychologist in the team could be very beneficial to the management of the 30-40% of COPD patients who may have some sort of psychological problems.

We are now linking the respiratory service to other services such as the new rapid response team, so if a patient deteriorates they will be visited by a community matron within four hours and given antibiotics at home. We are also looking at the possibility of giving IV antibiotics at home. The aim is a seamless service to minimise admission to hospital where possible if patients deteriorate.

First steps

As this was the first year of PBC we didn't have any savings we could use to fund such a service, so the PCT agreed to fund it initially with £250,000 of pump-priming money. We examined the patient pathways, looked at costings and took the plan to the local development plan group who agreed funding.

Once the funding was arranged we had to find premises. Luckily for us, the PCT was making available LIFT buildings, one of which became a clinic for the service with a team made up of consultant physician Dr Rod Storring – who had previously been working at King George, a local hospital – as well as a respiratory nurse and a psychologist employed through the provider arm of the PCT.

The process of putting the business plan together, looking at different pathways of treatment and bringing together a team, took about six months.

Referral and treatment

In the first year GPs were referring patients to the consultant directly – for example, those for whom we had a problem with diagnosis, or patients who had been admitted to hospital. We have now linked

to the local acute trust so that if patients present in hospital with a COPD exacerbation, where possible they are discharged within 24 hours of admission. The respiratory team will then follow them up in the community and manage them at home so we are reducing the length of hospital stay. The acute trust is finding this very helpful.

Newly diagnosed chronic patients are offered treatment in line with the British Thoracic Society guidelines – use of inhalers and medication, plus a look at whether they need oxygen at home (which the team will set up and educate patients to use). If appropriate, patients are referred back to general practice for smoking cessation.

The service does not see all the COPD patients in the practices, only those with problems. This is roughly 20 to 30 from each practice – about 600 to 700 patients.

Results

In the first year we had a £250,000 saving from the reduction in admissions. This covered the first year's costs so the service is now self-funding. In the second year the service generated £298,000 of savings. In the next year we expect even more savings.

The scheme had to be marketed and for the first three to four months it wasn't very busy, but it is now working at capacity. Thanks to this success the scheme has now been expanded. The consultant will see problematic asthma cases, and other lung conditions.

The COPD service offered 1,100 outpatient appointments in 2007/8. Comparing the financial year 2007/8 with 2006/7, for patients admitted into secondary care with a primary diagnosis of COPD we saw a reduction in the number of:

• emergency admissions of 11.7%• emergency readmissions of 23.7%• emergency readmissions within 30 days of 36.8%• bed-days of 18.2%.

The patients are very happy. In the past the only option in a COPD exacerbation was admission. Patients are now often being kept out of hospital and are delighted to have a consultant in the community who is willing to visit them at home.

The service can also feed into a pulmonary rehabilitation programme so patients become experts in their own condition. This had already been set up by the PCT but it hadn't been used properly until now.

In the first phase we were looking at preventing admissions and improving care of COPD patients. We are now on to the second level and are hoping to take on another respiratory nurse so we can increase the number of diagnoses made by screening those who might possibly have COPD.

Dr Gurkirit Kalkat is PBC cluster lead for Barking and Dagenham Quality Health Care consortium and chair of the Barking and Dagenham PCT PBC steering group

The psychologist's view

Dr Joanna O'Sullivan, is the chartered Counselling psychologist working with respiratory and CHD patientsI take referrals from the respiratory service, community matrons and a new urgent care team that manages patients at home.

When patients come to me I initially assess whether the psychological problems are caused by COPD or whether they have other mental health problems alongside the COPD. If the COPD is not part of the presentation of the problem I refer to mental health services.

Once I've assessed the symptoms and restrictions on the person's life, such as the anxiety caused by breathlessness, together with the patient and possibly their family we try to come to an agreed understanding about how the COPD is affecting their life. We then think about what we could do from a psychological point of view in terms of making changes to their behaviour.

I look into what it is that stops them from doing certain things – for example, if someone has a profound cough they may avoid going to the cinema, so we would look at the costs and benefits of doing that in terms of the quality of life the patient has. I get patients to think through their own behaviour and the thoughts and beliefs behind that behaviour.

In terms of managing their COPD I can help with relaxation and breathing. I build on the work the pulmonary rehab group and the physiotherapist do with the patient's breathing and exercise. I look at what the patient can do if they start to panic - one of the key psychological manifestations of COPD – and how in those situations they can use the breathing exercises that the physiotherapist has taught them.

I can also help with changes in their relationships where they have gone from feeling like two partners to being ‘the well one and the sick one' and I'll work with them both together to help them re-establish life as a couple.

Using psychology can help normalise the idea that people can have quite a tough time coping with managing COPD. I can reassure them that we don't think they have mental health problems, it's one of the consequences of the COPD.We review each session to see if the approach is working and I feel the service is making a big difference to some patients in terms of managing their COPD and the psychological consequences.

The consultant's view

Dr Rod Storring is the consultant working in the new COPD service‘Three years ago I was a consultant physician working at King George hospital – a local DGH. I have always thought things didn't connect very well in the health service and that it would be interesting to work in the community.‘I approached the local PCTs that fed into King George, and Barking and Dagenham responded with the offer of a job to work in the community.

‘Patients are mostly referred by their GP and new patients see me first then either me or the respiratory nurses for follow-up. We also have a rapid response team so nurses can be called to go and see patients at home. The patients are given a rescue pack and shown what to do. I prescribe it and write the instructions, then they contact their doctor two to three days into the course to discuss how they're getting on.

‘The patients love the service. There are no problems with parking and they get to see a consultant rather than a junior. GPs also like it.‘As well as seeing patients in the clinic, I will go into the GPs' surgeries where they gather a few patients for me to see. I'm also involved in training community matrons and helping them with advice.

‘I think this is the way forward. Chronic diseases can be much better organised and managed then they are at present.'

A psychologist in the team benefits the 30-40% of COPD patients with psychological problems.

In the first year we had a £250,000 saving from the reduction in admissions.